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Last Modified: 6/17/2021 Location: FL, PR, USVI Business: Part A, Part B

Checklist: Psychotherapy services documentation

This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for psychotherapy services. Health care providers retain the responsibility to submit complete and accurate documentation.

Check documentation requirements

Documentation is for the correct beneficiary
Documentation contains a valid and legible signature
Documentation clearly identifies the person performing the service including the title, education background, and credentials
Documentation clearly demonstrates session start and stop times and/or total time spent providing psychotherapy services to the beneficiary
Documentation demonstrates the type of service being provided including the therapeutic techniques and approaches, modalities, and frequencies of treatment furnished
Documentation supports the medical necessity for psychotherapy treatment including results of clinical tests, medication prescription and monitoring, any summary of diagnosis, functional status, treatment plan, symptoms, prognosis progress, and progress to date
Documentation to support "incident to" guidelines (if applicable), that includes evidence of the billing provider supervision and ongoing participation in patient care
For services that include an evaluation and management (E/M) component, the E/M services should be documented.
If applicable and required, submitted documentation should include a beneficiary waiver of liability.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.